Group 5 Verification Dependent Page 1 of 4

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SECTION A – PARENT HOUSEHOLD INFORMATION

Parent’s Marital Status (please check one):

___ Never Married ___ Legally Married or Remarried ___ Divorced ___ Separated ___ Widowed

Include in the household:

• Yourself and your parent(s) (including stepparent) and

• Your sibling(s)/stepsibling(s), even if they don’t live with your parent(s), if

(A)Your parent(s) provide more than half of their support from July 1, 2021 through June 30, 2022, or (B)Any of the children would be required to report your parent(s) information on the FAFSA; and

• Other people, if they now live with your parents and your parents provide more than half of their support, and will continue to provide more than half of their support from July 1, 2021 through June 30, 2022.

Read all of Section A above to determine who to list in your household below

FULL NAMES OF THOSE IN

HOUSEHOLD AGE RELATIONSHIP COLLEGE

WILL BE ENROLLED AT LEAST HALF TIME

(if attending college) (Your parent(s) should be listed in the

household)

NO



Check here, if there are more than six family members. Attach a list with each family member’s name, date of birth (month/year), relationship, college (if enrolled), and if they will be enrolled at least half time.

SECTION B – INCOME INFORMATION

Please submit student and parent(s) income by following the directions below:

1. Tax filer: If eligible, update tax information on the FAFSA using the IRS Data Retrieval Tool (DRT), if you have not already done so. If you are unable or ineligible to complete the IRS DRT you will need to submit a 2019 IRS Tax Return Transcript. To obtain a free IRS Tax Return Transcript, go to https://www.irs.gov/individuals/get-transcript or call 1-800-908-9946. If you have problems obtaining an IRS Tax Return Transcript, please call 1-800-829-1040 for assistance. In most cases, the IRS DRT may be used as acceptable documentation. Please see the Verification Guide Sheet for details.

Please note that personal identifiable information cannot be accepted by the University of Utah via email. This would include, but not be limited to, any tax document, social security card, driver's license, passport, citizenship document, etc. Please mail, fax or bring these documents to our office.

2. Non-Tax filer: If you and/or your parent(s) were not required to file taxes please submit a copy of the "Non-Filer Statement" located on our website (http://financialaid.utah.edu/forms).

Parent:

Student:

TAX RETURN FILER: The parent filed or will file a 2019 income tax return with the IRS

TAX RETURN NON-FILER: The parent will not file and is not required to file a 2019 income tax return with the IRS.

TAX RETURN FILER: The student filed or will file a 2019 income tax return with the IRS

TAX RETURN NON-FILER: The student will not file and is not required to file a 2019 income tax return with the IRS.

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Student Name: Student ID:

SECTION C – HIGH SCHOOL COMPLETION STATUS

For FAFSA verification purposes, please attach one of the following items to document successful completion of high school or the equivalent of a high school diploma:

Please note that personal identifiable information cannot be accepted by the University of Utah via email. This would include, but not be limited to, any tax document, social security card, driver's license, passport, citizenship document, etc. Please mail, fax or bring these documents to our office.

SECTION D – CERTIFICATION AND SIGNATURES

STUDENT SIGNATURE: DATE:

PARENT SIGNATURE: DATE:

You MUST sign and date this form. Your signature indicates that all information provided on this form is correct, and any requested documents will be provided to verify the reported amounts. Warning: if you purposely give false or misleading information on this worksheet you may be fined, sentenced to jail, or both.

The University of Utah is an Equal Opportunity and Affirmative Action institution. For detailed information or to request a reasonable accommodation, visit https://utah.edu/nondiscrimination

☐ High School Diploma - Acceptable documentation includes: (a) A copy of the applicant’s high school diploma; or

(b) A copy of the applicant’s final high school transcript that shows the date when the applicant completed secondary school education.

Note: In cases where a copy of an applicant’s high school diploma or final high school transcript is unavailable, e.g., the school is closed or located in a foreign country and the records are not available, an institution may accept alternative documentation to verify the applicant’s high school completion status such as Secondary School Leaving Certificate from the student’s national education ministry.

☐ Recognized Equivalent of a High School Diploma - Acceptable documentation includes: (a) General Educational Development (GED) Certificate;

(b) A State certificate received by a student after the student has passed a State-authorized examination that the State recognizes as the equivalent of a high school diploma;

(c) An academic transcript of a student who has successfully completed at least a two-year program that is acceptable for full credit toward a bachelor’s degree; or

(d) For a person who is seeking enrollment in an educational program that leads to at least an associate degree or its equivalent and has not completed high school but has excelled academically in high school, documentation from the high school that the student excelled academically in high school and documentation from the postsecondary institution that the student has met the formalized, written policies of the postsecondary institution for admitting such students.

☐ Homeschool - Acceptable documentation includes:

(a) A transcript or the equivalent, signed by the parent or guardian, that lists the secondary school courses completed by the applicant and documents the successful completion of a secondary school education; or

(b) A secondary school completion credential for homeschool (other than a high school diploma or its recognized equivalent) provided for under State law.

Please list the state in which you were homeschooled: _____________

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Only use this page if you are going to sign this form in person at the University Office of Scholarships and Financial Aid. If you cannot sign this form in person, complete Section F on page 4 to be signed in the presence of a notary.

SECTION E – IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE

- In Person

The student must appear in person at the University Office of Scholarships and Financial Aid to verify his or her identity by presenting a valid government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID, or passport. The institution will maintain a copy of the student’s photo ID that is annotated with the date it was received and the name of the Official at the institution authorized to collect the student’s ID.

In addition, the student must sign in the presence of the institutional Official a Statement of Educational Purpose provided below.

Statement of Educational Purpose

I certify that I, am the individual signing this Statement of Educational Purpose

(Print Student’s Name)

and that the Federal student financial assistance I may receive will only be used for educational purposes and to pay the cost

of attending the University of Utah for 2021-2022.

(Student’s Signature) (Date)

Name of Official at the Institution Accepting Form

(Official’s Signature) (Date)

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Student Name: Student ID:

Only complete this form with a NOTARY if you are unable to come into the University Office of Scholarships and

Financial Aid.

This page is not required if you submit page 3 (Section E) in person at the University of Utah. You will need to MAIL this form and a copy of the ID used for this acknowledgement to the Financial Aid Office. This form cannot be faxed or emailed.

SECTION F – IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE

- To Be Signed With Notary

If the student is unable to appear in person at University of Utah to verify his or her identity, the student must provide:

(a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the notary statement below, such as but not limited to a driver’s license, other state-issued ID, or passport; and

(b) The original notarized Statement of Educational Purpose provided below.

Statement of Educational Purpose

I certify that I, am the individual signing this Statement of Educational Purpose

(Print Student’s Name)

and that the Federal student financial assistance I may receive will only be used for educational purposes and to pay the cost

of attending the University of Utah for 2021-2022.

(Student’s Signature) (Date)

Notary’s Certificate of Acknowledgement

State of City/County of

On , before me, ,

(Date) (Notary’s name)

personally appeared and provided to me on basis of

(Printed name of signer) satisfactory evidence of identification

(Type of government-issued photo ID provided) to be the above-named person who signed the foregoing instrument.

WITNESS my hand and official seal

(seal) ________________________________________

(Notary signature) My commission expires on

(Date)

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correctly fill out Section A please note how "parent" is defined within the federal financial aid context:

• If your parents are both living and married to each other, give an account of their combined household and income information.

• If your parents have divorced or separated, give an account of the household and income information of that parent with whom you lived most during the past 12 months. If you did not live with one parent more than the other, answer in terms of the parent who provided the most financial support during the past 12 months.

• If your widowed or divorced parent has remarried as of when you submit your documentation for verification, give an account of the household and income information, which includes both your parent and the person whom he/she has married.

• If your parent is widowed or single, give an account of his/her household and income information. Include in college:

• Yourself, as indicated;

• Other members of your parents’ household, if they will attend at least half time in 2021-2022 academic year, and they are in a program that leads to a college degree or certificate.

• In college does not include household members who are in high school and are registered in a concurrent enrollment program.

Section B – Income Information:

1. Tax Filer

Acceptable tax forms for verification are the 2019 IRS Tax Return Transcript or tax information provided by the IRS through the Data Retrieval Tool available through your FAFSA. 1040 forms are accepted only if attempt to obtain the IRS

Tax Return Transcript is unsuccessful and must be documented. Tax Account Transcript are not acceptable tax forms for verification.

Please note that personal identifiable information cannot be accepted by the University of Utah via email. This would include, but not be limited to, any tax document, social security card, driver's license, passport, citizenship

document,etc. Please mail, fax or bring these documents to our office.

For individuals with unusual circumstances, please contact the University Office of Scholarships and Financial Aid for instructions on documentation to submit. This includes individuals who were granted a filing extension by the IRS, filed an amended IRS income tax return, victims of IRS tax-related identity theft, and individuals who filed a non-IRS income tax return.

2. Non-Tax Filer

If you or your parent did not file 2019 taxes you must provide the institutional Non-Filer Statement form and a copy of all wage statements or W-2s received in 2019. Additional information can be found on the Non-Filer Statement form located on our website at financialaid.utah.edu/forms

Please note that personal identifiable information cannot be accepted by the University of Utah via email. This would include, but not be limited to, any tax document, social security card, driver's license, passport, citizenship